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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202705
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:44:58 AM


Document Has Been Signed on 02/13/2024 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:CRESCENT OAKSFACILITY NUMBER:
435202705
ADMINISTRATOR:OLLIE VANCEFACILITY TYPE:
740
ADDRESS:147 CRESCENT AVETELEPHONE:
(408) 730-4004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:44CENSUS: 28DATE:
02/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ollie VanceTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Ollie Vance, Administrator. The purpose of the visit was to address two separate incidents of medication errors that both occurred on 10/02/2023 and were self-reported by the facility via Unusual Incident Reports (UIR). The first medication error involved staff S1 giving resident R1 another resident's medication. The second medication error involved staff S1 combining all residents' 5:00 PM and 8:00 PM medications and giving them to resident R2. Both UIRs reported that staff monitored both R1 and R2 for any changes in condition after the medication errors and their families and primary care physicians were notified.

During visit, LPA Marrufo obtained copies of the following documents: Disciplinary Notice for S1, In-Service Training Records from 03/02/2023, 07/17/2023, 09/20/2023, and 10/04/2023, Med Room Checklists from 12/28/2023 and 01/05/2023, and Medication Cart Audit from 02/09/2024.

LPA Marrufo requests that Administrator Ollie Vance submit a Plan of Action to address the ongoing staff training and mitigations that will be put in place to prevent future medication errors.

An Advisory Note was issued. See LIC9102 for more information.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Ollie Vance and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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